CQC Action Plan Progress Update

We are keeping track of the progress we are making on actions following the Care Quality Commission (CQC) comprehensive inspection in November 2016.

Clinical Teams are working to deliver the required improvements to ensure high quality care for the people we are here to serve, who require and use services.


The CQC inspected the Trust in November 2016 and published findings in reports on 30 March 2017. The reports ask the Trust to take a number of actions to improve in certain areas.

Action plans have been created for the provider and each core service report and identify the target dates for completion and the responsible leads.

A monthly Executive led oversight group has been established to ensure improvements are being made and to keep progress on track.

Once actions are completed, Care Standard Peer Inspections (CSPIs) are carried out to determine whether actions have been achieved and can be evidenced / demonstrated in practice.

The CSPIs are undertaken by a team comprising ‘peer’ staff and service users.

Once the CSPI Team is satisfied the action has been completed and there is evidence to demonstrate improvement the action is ‘signed off’ and turns blue.

There are 88 actions in total: 39 ‘Must do’ actions and 49 ‘Should do’ actions.

44 actions (50%) are complete (green) or complete and CSPI checked (blue).

No actions are off track (red).

  • Red ‘Off Track’ = 0
  • Amber ‘On Track’ = 44 (50%)
  • Green ‘Complete’ = 26 (30%)
  • Blue ‘Complete & CSPI’ = 18 (20%)

Please email CQCsupport@shsc.nhs.uk if you have any questions related to any of the action plans or their content.